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1 MOTOR ACCIDENT CLAIM FORM Please do not obtain any quotations. We will appoint an Assessor to assess the damage to your vehicle. Clear copy of Driver s licence to be submitted with claim form. Insured Policy. of insured (cellphone) (business) Occupation Vehicle Make Model Odometer Reading Value Tare Gross Vehicle Mass Registration Date of purchase Purchase price R If vehicle is subject to a Hire Purchase, Credit or Leasing Agreement, state name and address of Finance Company: Damage Damage to own vehicle Driver Full Foreign National Yes - if yes : Do you have SA residency? Yes - if yes : Date SA residency obtained State fully the purpose for which the vehicle was being used CPT ADDRESS 4th Floor, Gihon Building, Cnr. Bill Bezuidenhout and Sportica Road, Tygervalley POSTAL PO Box 5777, Tygervalley, 7536 DBN ADDRESS 1st Floor Units 5 & 6, Aloe Block, Fairway Green, 3 Abrey Road, Kloof, 3610 POSTAL PO Box 591 Gillitts 3603 JHB ADDRESS Ground Floor, Unit 2, Bruton Office Park, 18 Bruton Road, Bryanston POSTAL PO Box , Bryanston 2021 MUA Insurance Acceptances (Pty) Ltd (Registration number 2008/011925/07) is an authorised Financial Services Provider (FSP.: 37947) underwriting on behalf of Auto & General Insurance Company Limited (Registration number 1973/016880/06), an authorised Financial Services Provider (FSP.: 16354). DIRECTORS V J Hayter C Y Fourie (Managing Director) T Muranda R Farrell D Loots WEB

2 Driver Was the vehicle being used with your permission? Yes Was the driver in your employ? Yes Has the driver any motor insurance? Yes If YES, please state Policy Insurer Details of any convictions for motoring offences Has licence been endorsed? Yes Does the driver have any physical defects? Yes Details of previous accidents Advanced Driving Course? (If yes please attach certificate) Yes Passengers details (in insured vehicle) 1. and surname Injury 2. and surname Injury 3. and surname Injury 4. and surname Injury For what reason were they being transported? Are they employees? Other party details Damage to other vehicle Type of usage Reg.. Make / Model Type of usage Reg.. Make / Model Motor Accident Claim Form 2015 version 2 2

3 Other party details Type of usage Reg.. Make / Model Type of usage Reg.. Make / Model Damage to property other than vehicles of owner of owner of owner Personal Injuries (other than in Insured vehicles) Motor Accident Claim Form 2015 version 2 3

4 Witness Theft Was vehicle locked? Yes Who has the keys? Police station Engine number Colour Police Case number Chassis number VIN number Details of accessories stolen Anti-theft device? Yes Incident details Date Time Province Intersection Speed before accident Weather conditions Road surface Which vehicle lights were on? Suburb Speed on impact Visibility Width of road Street lighting Was any warning, e.g. hooting, indication etc. given by you? Yes Police Case. Was the driver tested for alcohol or drugs? Yes Police station Result of test Motor Accident Claim Form 2015 version 2 4

5 Incident details Description of accident (include intersection) Sketch of Accident (if necessary, please use a separate page). Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety or warning signs in the vicinity of the scene of accident. Declaration I/We understand that the completion of this form does not bind the Company to payment of any claim. I/We further declare that the foregoing particulars are true in every respect and that I/we have not withheld from the Company any information connected with the loss: Signature of driver Date Signature of insured Date Capacity NB. It is important that you notify Insurers immediately you become aware of any impending prosecution, inquest or demand Motor Accident Claim Form 2015 version 2 5